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Diagnosis: home UPT: highly sensitive at the time of missed cycle (positive at 8-9 d); bHCG
rises to 100,000 by 10 weeks and levels off at10,000 at term; can get gestational sac as early as
5 weeks. At that point your bHCG should be 1500 to 2000.
Discriminatory Zone: This means that when BHCG is 1200-1500, evidence of a pregnancy
should be seen on transvaginal ultrasound. When the BHCG is 6000, you can see evidence on a
transabdominal ultrasound.
Dating Age (not used except on tests!): weeks and days from fertilzation; GA 2 weeks greater
than DA
Ultrasound: can be 1 week off in the first trimester, 2 weeks off in the second trimester, 3 weeks
in the third trimester so… if your US differs from the EDC by LMP more than this, accept the US
dating over the LMP dating. In the first half of the first trimester, use the Crown Rump Length
(CRL) which is within 3 – 5 days of accuracy.
1. CV –
a. CO inc by 30-50% @ max 20 – 40 weeks
b. SVR dec secondary to inc. progesterone and therefore smooth muscle relaxation
c. BP dec: systolic down 5 – 10/ diastolic down 10 – 15 until 24 weeks then slowly
returns.
2. Pulmonary:
a. TV inc 30 – 40%
b. Minute Vent inc 30 – 40%
c. TLC dec 5% secondary to elevation of diaphragm
d. PA O2 and pa O2 inc; dec pA CO2 and pa CO2
3. GI:
a. Nausea and vomiting in 70% - inc. estrogen, progesterone and HCG; resolves by
14 – 16 w
b. Reflux – dec. GE sphincter tone
c. Dec lower intestinal motility, inc water reabsorption and therefore constipation
4. Renal
a. Kidneys increase in size
b. Ureters dilate – increased risk of pyelonephritis
c. GFR inc 50% - BUN, Crt dec 25%
5. Heme
a. Plasma volume inc by 50%, RBC vol inc 20 – 30% - drop in Hct
b. WBC still nl at 10 – 20 in labor
c. Hypercoaguability
d. Inc. fibrinogen, inc factors 7 – 10, dec 11 – 13
e. Slight dec in plt, slight dec in PT/PTT
6. Endocrine
a. Inc estrogen from palcenta; dec from ovaries – low estrogen levels assn with
fetal death and anencephaly
b. Progesterone is produced by corpus luteum then the palcenta
c. HCG – doubles roughly every 48 hours; peaks at 10 – 12 weeks; the alpha
subunit looks like LH, FSH and TSH but the beta subunit differs
d. Inc in thyroid binding globulins
7. Musculoskeletal/Derm – Spider angiomata, melasma, linea nigra, palmar erythema
a. Change in the center of gravity – low back pain.
8. Nutrition – 2000 – 2500 cal/day
• need to increase protein, calcium and iron- an iron supplement is
needed in the second trimester. 30 mg of elemental iron is
recommended
i. folate is necessary early on to prevent nueral tube defect (spina bifida) –
400 mcg per day is recommended in women without seizure meds or
previous infant with neural tube defect (4g are recommended then)
ii. 20 – 30 lb weight gain is OK, obese women do not have to gain weight.
Prenatal Care
First Trimester: CBC, Blood Type and Screen, RPR, Rubella, Hep B s Ag, HIV, UA/Cx, GC, Chl,
PPD, Pap Smear (without cytobrush)
Appt q mo.
Doppler FHT @ 10 – 12 w
OK Drugs: Tylenol, Benadryl, Phenergan
Routine labs q visit: FHT, Fundus height, Urine dip (prt, bld, glucose, etc), weight, BP
Third Trimester: RPR, CBC, Group B Strep 35-37 weeks (if not scheduled for repeat cesarean),
cervical exam every week after 37 weeks or the onset of contractions
Labor precautions: “Go to L&D if you have contractions every 5 minutes, if you feel a
sudden gush of fluid, if you don’t feel the baby move for 12 hours, or if you have bleeding
like a period. It’s normal to have mucus or a pink discharge in the weeks preceding your
labor.”
Amniocentesis can be done to get baby’s karyotype if abn US, aberrant MSAFP, Adv
Maternal Age or Family history of abnormalities
Can do a Chorionic Villi Sampling @ 9 – 11 weeks if you need a karyotype sooner, have
inc. risk of PPROM, previable delivery, fetal injury however.
PUBS: percutaneous umbilical blood sampling: gets fetal blood to test for degree of fetal
anemia/hydops in Rh disease, etc.
Fetal Lung Maturity:
Lecithin/Sphingomyelin Ratio: over 2.0 indicates fetal lung maturity
“FLM”: Flouresence Polarization: >55mg/g is mature; good for use in diabetics
Phosphatidyl glycerol: comes back pos or neg: best for diabetics because is last test to
turn positive; hyperglycemia delays lung maturity
Clinic Survival Guide Copy and put in your pocket!
Clinic note:
21 yo G2P1001 at 28 2/7 by 8 week ultrasound (always include dating criteria) complaining
of inguinal pain on walking. Denies contractions, vaginal bleeding, rupture of
membranes, and has fetal movement (the cardinal questions of obstetrics).
BP 110/68 Urine: trace protein (pregnant women usually have trace protein) neg
glucose
Fundal Height(FH): (measured from the pubic symphysis to fundus- correlates within 1-2 cm unless
obese) 29cm
Fetal Heart Tones (FHT): 140s (count them out on your watch in the beginning; normal 120s-160s)
Extremities: no calf tenderness
(any results of recent ultrasounds, lab work here)
A/P: 1. IUP at 28 2/7: size appropriate for dates
2. Round Ligament Pain: recommended maternity belt
3. RH Neg: Rhogam 300 mcg IM today
3. Continue PNV/ Fe, discussed preterm labor precautions
4. O Sullivan today
I.M. Student, L3
Complaints:
Discharge do cultures, wet prep (look for trich); mucus normal at term
The baby doesn’t move at times babies go through normal sleep cycles. As
long as it moves every couple of hours, that’s fine. Kick counts- lie on side and
count the amount of kicks in one hour after dinner- should be over 10.
Ectopic Pregnancy
Most common place – ampulla of the fallopian tubes; also located in ovary, abd wall,
cervix, bowel
Risk factors: Infx of tube, PID, IUD use, previous tubal surgery, assited reproduction
Occur in 1/100 pregnancies
SS: episodic lower abd pain
o Abnormal bleeding: due to inadequate progesterone support
o HCG decreased: normally, HCG doubles every other day; in ectopics it doesn’t
o Unilateral tenderness
o +/- mass
o Cullen’s sign (periumbical Hematoma)
o U/S finding- complex adenexal mass, can see sac or fetus, even
TX: Methotrexate 50 mg/m2 if <4 cm, unruptured: follow serial HCGs 4 and 7 days later.
You want the value to drop 15% between days 4 and 7. If it doesn’t, you give another
dose of methotrexate. If the mass is > 4 cm then salpingostomy or salpingectomy (if
patient is stable, can do this laparoscopically; if not needs emergent laparotomy)
Arias-Stella Rxn: assn with ectopic pregnancy; endometrial change that looks like clear
cell carcinoma (but is not cancerous)
Spontaneous Abortions ( <20 weeks)
Chromosome Stuff
Statistical Stuff
Maternal Mortality = mat death/100,000 live births
Fertility rate = # live births/1000 females 15 – 44
Birth rate = # live births / 1000 people
NST = Non Stress Test: to be “reactive” need 2 accelerations, of 15 beats per minute
for 15 seconds in 20 minute strip; if nonreactive, baby can be sleeping – give mom
juice – do a BPP (think about sedatives, narcotics, CNS/CV abnormalities)
BPP = biophysical profile; on U/S 8 pts good/ 4 pts bad
DATING
Menstrual History: 40 weeks from LMP (Naegle’s rule: LMP + 7 days – 3 months)
Uterine Size:
o 10 Weeks grapefruit size
o 20 weeks is at umbilicus
o 20 – 33 weeks matched dates +- 2 cm of Fundal Height
o may not match at term due to descent
Ultrasound: is most accurate at 8 – 12 weeks
Dating Criteria for delivery: determines whether lungs are considered mature for delivery
1. FHT documented 30 weeks by Doppler.
2. 36 weeks since UPT positive.
3. US of CRL at 6-11 weeks makes gestational
age >39 weeks.
4. US of under 20 weeks supports gestational
age >39 weeks.
STAGES OF LABOR
First: beginning of contractions to complete cervical dilation
o Latent – to approx. 4 cm (or acceleration in dilation)
o Active – to 10 cm complete; prolonged if slower than 1.2 cm/hr null/1.5 cm/h
multip; if prolonged, do amniotomy, start pitocin, place IUPC to evaluate
contraction strength
o Failure to progress – no change despite 2 hours of adequate labor (MVU >200)
Second: complete dilation to the delivery of baby
o Prolonged if 2 hours multip/ 3 hours nullip (with epidural) or 2 hours nullip/1
hour multip (no epid)
Third: delivery of baby to delivery of placenta
o Can take up to 30 mins
o Signs include increase in cord length, gush of blood, uterine fundal rebound
Fourth: one hour post delivery
3 P’S OF LABOR
1. Power: nl contractions felt best at fundus; last 45-50 seconds; 3 in 10 minutes
2. Passenger:
a. Presentation – what is at the cervix (head (vertex), breech)
b. Position – OA, OP, LOT, ROT
c. Attitude – relationship of baby to itself
d. Lie – long axis of baby to long axis of mom
e. Engagement – biparietal diameter has entered the pelvic inlet
f. Station – presenting part’s relationship to ischial spine (-3, -2, -1, 0, 1, 2, 3)
3. Pelvimetry:
a. Inlet: Diagonal Conjugate – symphysis to sacral promontory = 11.5 cm
Obstetrical Conjugate – shortest diameter = 10 cm
b. Midplane: spines felt as prominent or dull
c. Outelt: Bituberous Diameter = 8.5 cm
Subpubic Angle less than 40 degrees
FORCEPS
Outlet forceps: requirements –
visible scalp
Skull on pelvic floor
Occiput Anterior or Posterior
Fetal head on perineum : can see without separating labia
Adequate anesthesia; bladder drained
Maximum 45 degrees of rotation
Low forceps:
station 2 but skull not on pelvic floor
INDUCTION:
Indications: PreEclampsia at term, PROM, Chorioamnionitis, fetal jeopardy/demise,
>42w, IUGR
Bishop Scoring System: if induction is favorable: >8 vaginal delivery without induction
will happen same as if with induction: < 4 usually fail induction: < 5 – 50% fail induction
CARDINAL MOVEMENTS
Engagement – fetal head enters pelvis
Flexion – smallest diameter to pelvis
Descent – vertex to pelvis
Internal Rotate – sag suture is parallel to AP
Extend at pubic symphysis
Externally rotate after head delivery
INDICATIONS FOR C-SECTION
Failure to progress (P’s of labor)
Breech presentation with labor
Shoulder presentation
Placenta Previa
Placental Abruption
Fetal distress: 5 minutes of decal <90 bpm; repetitive late decals unresponsive to
resusitation
Cord Prolapse
Prolonged second stage of labor
Failed forceps
Active herpes
Prior classical C/S (has to do with incision on uterus not skin!)
2 prior low transverse c/s (VBACs are controversial)
Ultrasound
Anesthesia
Epidural anesthesia: lengthens second stage – may need oxytocin
Injected into L3/L4 interspace: use the technique of least resistance (the epidural space
has a negative atmospheric pressure so the syringe you place over the needle will
suddenly lose its resistance as you advance it into the epidural space, inject test dose)
Can cause hypotension after dosage because the autonomic nervous system is blocked
and all blood pools in extremities; can see late decals, but usually resolve with hydration
and blood pressure increase.
Paracervical block: not really done because can inject into fetus easily and cause fetal
bradycardia
Spinal: one time dose, shorter duration of action, used in repeat c/s
Pudendal Block: Can be done with vaginal delivery, inject analgesic into post-ischial spine and
sacrospinous ligament (takes 5 – 10 mins to set up: good for forceps delivery without epidural)
IUGR:
Causes: Htn, DM, renal dz, malnutrition, plac previa, abruption, CMV, Toxo, Rubella and
mult gest
Symmetric: insult was early in gestation ie. Viral
Asymmetric: late onset (ie. Tobacco); femur length is usually spared
Doppler velocimetry with end diastolic flow reversed or absent or nonreassuring fetal
heart tracing necessitates delivery.
OLIGOHYDRAMNIOS:
Amniotic Fluid index: divide mom’s belly into 4 quadrants – measure the largest pocket of
fluid in each <5: Oligohydramnios >20: Polyhydramnios
Absence of Range of Motion – 40X increase in Perinatal mortality
Assn with abnormalities of GU (renal agenesis = Potter’s Sd, polycystic kidney dz,
obstruction), and IUGR
Fetal Kidney/lung amniotic fluid resorbed by placeta, swallowed by fetus, or leaked
out into vagina.
Most common cause: ROM (rupture of membranes)
Dx: US
TX: If preterm, hydrate if fetus stable; If term, deliver
POLYHYDRAMNIOS:
AFI > 20 or 25; 2-3% of pregnancies; assn with NT defects; obst mouth, hydrops, mult
gest
Monitor with serial ultrasounds. Can do therapeutic amniocentesis.
Antenatal Hemorrhage
Preterm Labor
RF: low SES, nonwhite, <18 yo, mult gest, h/o preterm birth, smoking, cocaine, no PNC
uterine malformation, h/o CKC, Group B strep, Chlamydia, Gonorrhea, BV
SURVIVAL: 23 w 0-8% 24w 15-20% 25w 50-60% 26-28w 85% 29w 90%
ALGORITHM:
Good Dates
PROM
Chorioamnionitis
Cephalopelvic Disproportion
Face: chin is anterior for delivery, many anencephalics have a face presentation; dx on exam
Brow: must convert to occiput for delivery
OP: usually rotate to OA (manually)
Shoulder: transverse lie do c section
Compound: fetal extremity with vertex or breech cord prolapse; part will reduce as labor
occurs
PP Hemorrhage
Defined as > 500 ml blood loss following vag delivery, > 1000 ml blood loss following c/s
Causes
o Uterine atony coagulopathy
o Forceps uterine rupture
o Macrosomia uterine inversion
TX
o Vigorous fundal massage Oxytocin 20 U in 1000 ml NS
o Repair laceration Methergine 0.2 mg IM (contra: htn)
o Take out placental remnants PgF2 – alpha (Hemabate) (contra: asthma)
o Cytotec 800 mg rectal Hysterectomy if medical therapy fails
Rh Incompatibility
Mom is Rh neg (Rh is an antigen on the RBC: CDE family) + Dad is Rh pos = baby is be
Rh pos: during first pregnancy (usually at delivery but can occur with Sab,amniocentesis,
trauma, ectopic, etc), mom develops antibodies against Rh positivity (because she lacks
the antigen) which can cross the palacenta and cause a hemolysis in the newborn which
may cause death.
Kleihauer Betke Test: assess amt of fetal blood passed into maternal circulation
On first visit: blood type, also screen for other antibodies:
o Lewis – “lives”
o Kell – “kills”
o Duffy – “dies”
Zone 3 HDN
Zone 2
ffffsdfffollfollowfollclosely
Zone 1 Okay
Weeks gestation
IUFD assn with abruption, congenital anomalies, post dates, infection, but usually is
unexplained.
Retained IUFD over 3 – 4 w leds to hypofibrinogenemia secondary to the release of
thromboplastic substance of decomposing fetus sometimes DIC can result.
DX: no FHT on ultrasound
TX: delivery
Postdates :@ 41 w: do NST: if nonreassuring do induction
o 42w: do BPP and NST 2 q wk: if nonreassuring do induction
o inc risk of macrosomia: oligohydramnios, Meconium aspiration, IUFD
o DX: by LMP, u/s consistent with LMP in first trimester
o Induce after 42 w
Diabetes in Pregnancy
Priscilla White Classification: not used as much anymore
A1 diet controlled GDM (gestational diabetes mellitus)
A2 GDM controlled with insulin; polyhydramnios, macrosomia, prior stillbirth
B DM onset > 20 yo; duration < 10y
C onset 10-19 yo; duration < 20 y
D juvenile onset dur > 20 y
F nephropathy
R retinopathy
M cardiomyopathy
T renal transplant
Etiology : impairment in carbohydrate metabolism that manifests during pregnancy ;
50% in subsequent preg ; many get DM later in life.
Risk Factors: >25 yo, obesity, family history, prev infant >4000 g, prev. stillborn, prev.
polyhydramnios, recurrent Ab
Assn with: 4x more pre e, 2x more S Abs, inc. infx, inc. hydramnios, c/s, pp hemorrhage,
fetal death
Fetal anomalies:Transpostion of the great vessels, sacral agenesis, macrosomia, still
birth
DX: O’Sullivan (50 g glucose) @28 w over 140: fasting <105, 1 hr <190, 2 hr <165, 3 hr
<145
Management: ADA 1800 – 2200 kcal/d diet; glucose checks, insulin if necessary, deliver
@ 38-40 w oral glucose tolerance test after delivery in six weeks
Antenatal testing: @ 30-32 w US q 4w (look for IUGR, polyhydramnios), kick counts,
NST, BPP
Watch for neonatal hypoglycemia
CMV
SS baby: hepatosplenomegaly, thrombocytopenia, jaundice, cerebral calcifications,
chorioretinitis, interstitial pneumomitis, MR, sensorineural hearing loss, neuromuscular
d/o
Rubella
SS adults: maculopapular rash, arthralgia, lymphadenopathy for 2-4 d
SS infant: deafness, CV anomalies, cataracts, MR
Dx: IgM titers in infant
Do not give MMR vaccine to pregnant woman
No tx for rubella
Toxoplasmosis
First trimester infection: chorioretinitis, microcephaly, jaundice, hepatosplenomegaly
Adult SS: fever, malaise, lymphadenopathy, rash
Dx: percutaneous umbilical cord sampling, IgM ab
Tx: pyrimethamine (<14 w), spiramycin (less teratogenic)
Hepatitis B
Transm: sex, blood products / transplacental; can cause mild to fulminant hepatitis
Dx: ab markers: Hbs Ag
Vaccinated at birth now
Syphilis
Vertical transmission possible in primary and secondary syphilis
SS baby: hepatosplenomegaly, hemolysis, LAD, jaundice, saber shins
Dx: IgM antitreponemal ab
HIV
Vertical transmission possible; AZT decreases chances GREATLY
Inc transmission with inc viral burden/adv disease
Neisseria gonorrhea
Transmitted during birth to eye, oropharnyx, ext ear, anorectal mucousa
Disseminates arthritis, meningitis
Screening in early pregnancy
Tx: ceftriaxone, Suprax po
Chlamydia
40% babies get conjunctivitis
10% babies get pneumonitis
Tx: Zithromax, erythromycin
Hyperemesis Gravidarum
Coagulation Disorders
A hypercoaguable state can be due to inc. coag factors (all except 11, 12, dec turnover
time for fibrinogen), endothelial damage, and venous stasis (uterus compresses IVC and
pelvic veins) increased deep venous thromboses, septic pelvic thromboses and
pulmonary emboli.
Septic pelvic thrombosis: postpartum, prolonged fever on antibiotics; usually due to
ovarian veins; not likely to lead to emboli; tx is heparin, abx
Deep Venous Thromboses: SS: edema, erythema, palpate venous cord, tender,
different calf sizes; Dx: Doppler of extremity, venography; Tx: heparin IV (PTT x 2) then
sub Q heparin or lovenox in pregnancy (NO COUMADIN IN PREGNANCY: skeletal
anomalies, nasal hypoplasia); coumadin OK if post partum.
Pulmonary Embolus: DVT right atrium RV pulmonary arteries pulm htn,
hypoxia, RHF death.
SS: sob, pleuritic chest pain, hemoptysis, with signs of DVT
DX: Doppler ext, CXR, ECG, VQ Scan, Spiral CT Pulmonary Angiography
TX: IV heparin then SQ heparin or lovenox (coumadin OK postpartum)
Substance Abuse
EtOH: Fetal Alcohol Sd: growth retardation, CNS effects, abnormal facies, cardiac
defects
Tx: alcoholism: aggressive counseling; adequate nutrition
Caffiene: 80% exposed in first trimester
Tobacco: Inc. Sab, preterm birth, abruption, dec. birth weight, SIDs, resp disease
Cocaine: inc. abruption (from vasoconstriction), IUGR, inc PTL; as a child,
developmental delay
Opiates: (heroin/methadone); the danger is heroin withdrawal, not use miscarriage,
PTL, IUFD; tx: enroll in methadone program; do not restart methadone if patient has not
used for 48 hours.
Postpartum Care
Vaginal delivery: pain care/perineal care (ice packs, check for hemorrhage, stool
softener Pelvic rest x 6 w (no douching, tampons, sex); NSAIDS
C Section: local wound care, narcotics for pain, stool softeners, NSAIDS
Breast Care: Milk letdown occurs at 24 – 72 hr; if not breast feeding use ice packs, tight
bra, analgesia (breast feeding gives relief)
Mastitis: oral or skin flora enter a crack in breast skin; can be treated with dicloxacillin;
continue to breast feed.
Contraception: no diaphragms, caps until 6 w; if breast feeding depo, micronor; not
breastfeeding OCP, norplant, depo, Orthoevra
Post Partum Hemorrhage:
o Blood loss vag delivery = 500 cc; c/s = 1000cc (normal – remember, mom’s
plasma volume expands just for this reason!)
o Causes:
Uterine atony (RF: multip, h/o atony, fibroids) tx: pitocin, methergine, etc.
Retained products of conception: find on manual exploration of uterus
Placenta accreta: placenta is stuck in uterine wall
Cerv/Vag lacs: repair with adequate anesthesia
Uterine rupture (1/2000) ss: abd pain, “pop” tx: laparotomy and repair if
possible.
Uterine Inversion (1/2800) RF: fundal placenta, atony, accreta, excess
cord traction tx: manually revert, NTG, Laparotomy
Post Partum depression:
o Post partum blues: 50%; changes in mood, appetite, sleep, will resolve
o Post Partum depression: 5%; decreased energy, apathy, insomnia, anorexia,
sadness; can get better or proceed to psychosis; tx: antidepressants (SSRIs)
Congenital anomalies:
Labial fusion: assn with excess androgens develop abnormal genitalia tx: estrogen
cream
Imperforate hymen: the junction between the sinovaginal bulbs and the UG sinus is not
perforated obstructs outflow
o SS: primary amenorrhea at puberty, hematocolpos (blood behind hymen)
o TX: surgery
Vaginal septums: when vagina forms, the sinovaginal bulbs and mullerian tubercle must
be canalized. If not you get a transverse vaginl septum between lower 2/3 and upper 1/3
primary amenorrhea
o TX: surgery
Vaginal agenesis: Rokitansky-Kuster-Hauser Sd: mullerian agenesis/dysgenesis; may
have rudimentary pouch from sinovaginal bulb; Testosterone Insensitivity: 46 xy with no
sensitivity to testosterone (may have undescended testes)
o TX: surgical creation of vagina
Vulvar dystrophy: Hypertrophic: from chronic vulvar irritation = raised white lesions
o TX: cortisone cream bid
o Atrophic: dec estrogen to local tissues (postmenopausal)
o SS: dysuria/parunia, pruritus, Vulvodynia, lichen sclerosis et atrophicus
o Tx : 2% testosterone cream, hydrocortisone cream
Benign Cysts:
oEpidermal Cyst: occlusion of pilosebaceous duct/hair follicle
Tx: incision and drainage
o Sebaceous cyst: duct blocked – sebum accumulates
TX: I & D if infected
o Apocrine Sweat Gland Cyst: on mons or labia occludes glands
superinfection hidradentitis suppurative I & D, Doxycycline
o Bartholin’s gland Cyst: 4 or 8 o’clock on labia majora
TX: sitz baths, infx – I & D / word catheter
Cervical Lesions
o Congenital anomalies: DES exposure in utero = 25% congenital anomalies, clear
cell adenocarcinoma 1%
o Cervical Cysts: dilated retention cysts: nabothian cysts = blockage of
endocervical gland @ 1 cm – asx, no TX
o Mesonephric Cysts: (remnants of wolfian/mesonephric ducts) deeper in stroma
o Polyps: broad based = can have intermittent/post coital bleeding; usually
removed cervical fibroids = intermenst bleeding, dysparunia, bladder/rectal
pressure/ r/o cerv can
o Cervical Stenosis: congenital or after scarring (surgery/radiation) or secondary to
neoplasm or polyp; if asymptomatic, leave alone; if causes menstrual problems,
remove; gently dilate scarring.
Fibroids
Fibroids = Estrogen dependant local proliferation of smooth muscle cells, usually occur in
women of child bearing age and regress at menopause; African American are at higher
risk; has a pseudocapsule of compressed muscle cells; are found in 20-30% American
women at age 30
SS: menorrhagia (submucous), metrorrhagia (subserous, intramural), pressure sx (from
pressing against bladder), infertility; 50% are asymptomatic.
Parasitic fibroids: get their blood supply from the omentum.
Histologic Changes:
o Hyaline Change
o Cystic Change
o Calcific change
o Fatty Change
o Red/white infarcts
o Sarcomatous change (most rare)
In pregnancy are at increased risk for Sab, IUGR, PTL, Dystocia; may grow during
pregnancy
Med TX: Depo provera, Lupron (GnRH agonist), Danazol
Surg Tx: momectomy(only for fertility purposes), hysterectomy indicated when anemic
from bleeding, severe pain, size > 12 w, urinary frequency, growth after
menopause, new role for embolization by interventional radiology
Endometrial Hyperplasia
Endometrial hyperplasia: abnormal proliferation of gland/stromal elements;
overabundance of histologically normal epithelium
o Simple without atypia: 1% cancer- Provera
o Complex without atypia: 3% cancer- Provera
o Simple with atypia: 9% cancer- Provera vs. TAH
o Complex with atypia: 27% cancer- TAH
o RF: unopposed estrogen, PCO, granulosa/theca tumors
o DX: endometrial biopsy
Endometriosis
Ovarian Cysts
Treatment of STDs
Chlamydia trachomatis:
o DX – Direct fluorescent Ab
o Tx: doxycycline 100 mg bid x 7 d or Azithromycin 1 g po (one dose)
N. Gonorrhea:
o DX: gram stain, culture
o RF: low SES, urban, nonwhite, early sex, prev gon infx
o Treat both partners
o TX: Rocephin 250 mg IM or Cipro 500 mg po or Floxin 400 mg po
o Usually transfers male to female more than female to male.
Syphilis: Treponema pallidum
o DX: dark field microscopy
o TX: (<1 yr duration) Pen G 2.4 million U IM (>1yr duration) 2.4 mill U IM x 3
doses (see ob section for full description)
Herpes Simplex Virus: first episode – Acyclovir/Famciclovir/Valcyclovir; 66% HSV-2
33% HSV-1 of genital herpes; vesicles rupture in 10-22 d leaving a painful ulcer; can use
antivirals also as suppressing agents as the virus hangs out in the dorsal root ganglion.
HPV:
o Types 6/11 = genital warts
o Types: 16,18,31 = cervical cancer
o TX: podofilox, cyrotherapy, podophyllin rein, TCA, Aldara cream
Chancroid: casued by Haemophilus ducreyi; is a painful soft ulcer with inguinal
lymphadenopathy; tx with Ceftriaxone 250 IM x once or Azithromycin 1 g once po or
Erythromycin; treat partner.
Lymphogranulona venerum: primary = papules/shallow ulcer; secondary = painful
inflammation of inguinal nodes with fever, h/a, malaise, anorexia; Tertiary = rectal
stricture/rectovaginal fistula/ elephantiasis TX: doxycycline 100 mg po bid x 21 d
Molluscum contagiosum: pox virus from close contact; 1-5 mm umbilicated lesion
anywhere but the palms or soles; are asymptomatic and resolve on their own
Phthris pubis/sarcoptes scabei: Lice and scabies, respectively; TX: lindane/Kwell
Vaginitis
Candida:
o RF: Abx, DM, Pregnancy, immunocompromised
o SS: burning, itching, vulvitis, cottage cheese discharge, dysparunia
o DX: wet prep KOH = branching hyphae
o Exam: white plaques with or without satellite lesions
o TX: over the counter creams work well (monistat); if resistant, Diflucan 150 mg
po x once
Trichomonas: unicellular flagellated protozoan
o SS: itching, inc. discharge (yellow/gray/green), frothy
o Exam: strawberry cervix, foamy discharge
o DX: see the buggers zipping all over your wet prep
o TX: Flagyl 500 mg po bid x 7 d/ partner condom x 2 w
o Note: avoid flagyl in frist trimester
Bacterial vaginosis: Gardnerella vaginalis
o SS: odorous discharge
o DX: whiff test by adding KOH; see clue cells on wet prep (spotty squamous cells)
o TX: flagyl 500mg bid x 7 d
o Not an STD
Atrophy
o SS: burning d/c on sex
o RF: post menopausal
o TX: estrogen
PID
Organisms: Neisseria, Chylamadia, Mycoplasmia, Ureaplasma, Bacterioides, among others
SX: diffuse lower abdominal pain, vaginal discharge, bleeding, dysuria, dyspareunia, CMT,
adnexal tenderness, GI discomfort
DX: Cervical Motion Tenderness, Adenexal tenderness, discharge, fever, elevated WBC,
ESR
Lab: cultures, pelvic U/S if mass palpated, rise in WBC count
TX: Ceftiaxone 2 g IV q 12, Doxycycline 100 mg IV or Clindamycin – Gentamycin
Usually tx for 48 hrs IV then if afebrile change to Doxycyclin 100 mg po bid x 14 d
TOA: Tubo Ovarian Abcess: persistent PID progresses to TOA in 3-16% of the time
Adnexal mass/fullness (not walled off like true absess)
DX: U/S, Pelvic CT if obese, increase WBC with a shift to the left, increase ESR
TX: Hospitalize for IV antibiotics (Triples: ampicillin, gentamycin, clindamycin) if TOA ruptures or
doesn’t resolve with antibiotics then surgery.
ENDOMETRITIS: usually after some type of instrument disruption of the uterus: C-section,
vaginal delivery, D & E/C, IUD)
DX: endometrial or endocervical culture will result in skin, GI, repro flora
TX: Doxycycline vs. IV abx
TOXIC SHOCK SYNDROME: vaginal infection that is not associated with menstruation
Can be assoc with delivery, c-sections, post partum Endometritis, sab or laser tx of coac
Staph aureus produces epidermal TSS T-1 that produces fever, erythema rash
desquamation of palmer surfaces and hypotension. Also see GI disturbances, myalase;
mucus membrane hyperemia, change in mental status
Labs: increased BUN/CR, decreases plt; but neg blood cultures
TX: always hospitalize… may need ICU and give IV fluids and / or pressors. ABX do not shorten
the length of the acute illness but does decrease the risk or recurrence.
BLADDER ANATOMY
- Detrusser and urethra = smooth muscle
- Internal spincter is at urethrovesical jxn
- Incontinence = intraurethral < intravesical pressure
- PSNS (S2,3,4) allows micturition : CHOLINERGIC RECEPTORS
- SNS – hypogastric n. T 10 – L2 prevents urination by contracting bladder neck and internal
spincter : NE RECEPTORS
- Somatic controls external spincter (pudendal nerve)
PELVIC RELAXATION: damage to the anterior vaginal wall leading to cystocele, endopelvic
fascia leading to rectocele or enterocele or stretching of cardinal ligaments which can lead to
uterine prolapse
DX: mostly PE : called a POP Q, which is a graph on which certain points corresponding to
lengths of the vagina and where it moves on valsalva are graphed. This tells you where the defect
is, so you know the appropriate therapy from it.
SX: pain, pressure, dyspareunia, incontinence, bowel or bladder dysfunction
Causes: anything that will cause chronically increased abdominal pressure: cough, straining,
ascites, pelvic tumors, heavy lifting
RF: aging, menopause, traumatic delivery, associated with multiparity
PE: pelvic exam shows the amount of descent of the structure into the vagina and thus
determines the degree of relaxation: (POP Q)
Stage 1 – upper 2/3 of vagina
Stage 2 – to the level of the introitus
Stage 3 – outside of the vagina
TX: kegels (contraction of levator ani muscle, instructed by physician), estrogen replacement,
vaginal pessaries, surgery
INCONTINENCE:
URGE INCONTINENCE: aka detrussor instability
SX: urgency, often can not make it to the bathroom
Causes: foreign body, UTI, stones, CA, diverticulitis
Dx: based on history, can be shown on urodynamics (which is a catheter in the bladder, rectum
and a machine to measure the difference. The bladder is filled with normal saline and response to
that is measured.)
Urodynamics shows: involuntary/uninhibited bladder contractions
TX: Kegle exercises, anticholerginics (ditropan, amytriptaline), muscle relaxants, beta agonists,
estrogen replacement- surgery is not used here, more medical therapy is appropriate
STRESS INCONTINENCE:
SX: involuntary loss of urine when there is an increased abdominal pressure mostly from
sneezing, coughing, laughing which transmits pressure to the urethra
Mech: Intrinsic spincter defect, hypemobile bladder neck, pelvic relaxation
Causes: trauma, neurologic dysfunction, associated with multiparity
TX: Keglelexercises, alpha agonists, estrogen cream, retropubic urethropexy (which is a surgery
where the periurethral tissue is joined with the Cooper’s ligament – called a Burch) or Trans
Vaginal Tape procedure (the periurethral tissues are raised towards the abdominal wall using a
mesh sling- placed under local anesthesia)
OVERFLOW INCONTINENCE:
SX: dribbling, urgency, stress
Mech: underactive detrussor leading to poor or absent bladder contractions
Cause: DM, drugs, fecal impaction, MS, neurologic
TX : treat underlying cause, Hytrin, bethanechol, intermittient cath, dantroleen
DX: urodynamics, post void residual (after you pee, you place a catheter to see how much urine
is left in the bladder- over 100 cc is abnormal)
URINARY FISTULA: produces continuous urine leakage commonly seen following pelvic
surgery/radation
RF: PID, radiation, endometriosis, prior surgery
DX: Methylene blue dye injection into the bladder—place a tampon in the vagina- if it’s a
vesicovaginal fistula the tampon will be blue, indigo carmine dye given IV with a tampon in vagina
—if it’s a ureterovaginal fistula the tampon will be blue
TX: surgery but must wait 3 – 6 months to repair postsurgical fistulas
ENDOCRINOLOGY
Two pneumonics: (pick your favorite) “breast hair grow bleed” or “boobs pubes pits and pads”
TANNER STAGES
Breast Hair
1. Prepubertal 1. prepubertal
2. Breast bud 2. presexual hair
3. Breast elevation 3. Sexual hair
4. Areolar Mound 4. Mid-escutcheon
5. Adult Contour 5. Female escutcheon
WHI Study: What are all these questions about estrogen and progesterone on the news? In
women with active heart disease, estrogen and progesterone (prempro) increases the remote risk
of stroke and DVT. There were problems with this study, however.
There are no problems taking estrogen alone when you don’t have a uterus.
Swyer’s Syndrome: 46xy, gonadoagenesis, w/o testes no MIF yielding female genitalia but no
estrogen so no breasts.
Kallman’s Syndrome: absence of GnRH and anosomia. Pts have breast and uterus
Testicular Feminization: 46xy insensitive to testosterone. MIF so no internal female genital
structures + estrogen so has breasts.
PMS
2nd ½ of cycle
Probable Causes: abnormal estrogen/progesterone balance, increase PG production, decrease
endogenous endorphins; disturbance in renin-angiotensin-aldosterone system
DX: 5 of 12 symptoms (including 1 of the first four)
SX:
1. Decreased mood
2. Anxiety
3. Affective Liability
4. Decrease interest
5. Irritability
6. Concentration difficulty
7. Decreased energy
8. Change in appetite
9. Overwhelmed
10. Edema
11. Edema
12. Weight gain
13. Breast Tenderness
TX: avoid caffeine, etoh, tobacco, low sodium diet, weight reduction, stress management.
Drugs: NSAIDS, OCPs, lasix, calcium, vit E, SSRI
DYSMENORRHEA: pain and cramping during menstruation that interferes with the acts of daily
living.
Primary – presents <20 years b/c of increased PG occurs with Ovulatory cycles
Secondary – Endometriosis, Adenomyosis, fibroids, cervical stenosis (congenital, trauma,
surgery, infection), adhesions (h/o infection PID, TOA, ex lap LOA)
MENORRHAGIA
Heavy prolonged menstrual bleeding; over 80 cc/ cycle
Avg 35 ml of blood loss
> 24 pads per day
Estrogen increases endometrial thickness
Progesterone matures Endometrium and withdrawal of leads to secretion
Menstruation at regular intervals usually indicates ovulation
OVULATORY DUB:
Early spotting – estrogen no increasing fast enough
Mid spotting – estrogen drop off at ovulation
Late spotting – Progesterone def
TX: NSAIDS dec blood loss by 20-50%
HIRSUITISM / VIRILISM
Diagnosis/ Work up: assess body hair systematically
Free testosterone- ovary produces the most testosterone
DHEAS- adrenal produces the most DHEAS- screens for adrenal tumors
17 hydroxy progesterone- congenital adrenal hyperplasia
Hair type: Villus hairs – cover entire body
Terminal hairs – thick = Axillary, pubic, 5 reductase converts testosterone to dihydrotestosterone
to stimulate terminal hair development
• Hirsuitism – increase of terminal hairs esp on face, chest back, diamond shaped
escutcheon (male) increase 5 reductase
• Virilism – male features, deepening of voice, balding, increase muscle mass,
clitormegaly, breast atrophy, male body habitus
Causes: Adrenal tumor, ovarian tumor, PCO
Cushing’s syndrome: increase ACTH, cortisol
Congenital Adrenal Hyperplasia – 21 and 11 hydroxylase def
Polycystic Ovarian Syndrome: This is a syndrome which can include numerous ovarian cysts,
but really is more than that. It includes …
• Insulin Resistance: diagnosed by Fasting Glucose/ Insulin ratio <4.5 Tx: Metformin
• Hirsuitism: from hyperandrogenemia
• Anovulation: irregular, heavy periods; if desires fertility treat with metformin and clomid
• FSH : LH ratio is over 2.5:1
Work Up:
Sperm count- must be done first
TSH, Prolactin
HSG-hysterosalpingogram- assesses patency of tubes and diagnoses intrauterine defects
Post Coital test- looks at quality of mucus and sperm, done D#12-14
BBT- temperature curve- spike predictive of ovulation
Progesterone level on day 21- assess ovulation
Diagnostic Scope- looks for endometriosis
CHANGES IN VULVA
Lichen Sclerosis – thin skin, hyalinized collagen tx: clobetasol (a high potency steroid)
VAGINAL CA
-women in their 50’s
-DES exposure in utero resulting in clear cell adenocarcinoma
-asymptomatic for the most part but may have d/c, bleeding, purities
-TX: pap – Colpo – pathologic dx
Colposcopy: magnifies region of cervix after stained with acetic acid. Areas of dysplasia stain
WHITE (aceto white focal lesion) and are biopsied. An endocervical curettage is also done.
Treatment of dysplasia is based on the biopsy and ECC result. As a general rule…
• Mild dysplasia: observation, cryotherapy
• Moderate dyplasia: cryotheraphy or LEEP (loop electrosurgical excision procedure)
• Severe dysplasia: LEEP or Cold Knife Conization
• If ECC has dysplasia: CKC or LEEP
CERVICAL CANCER
Most cancer occurs in transformation zone
Koilocyte: has viral particle
HPV oncogenic 33, 35, 52,16, 18 ordinary wart 6,11
SX: vaginal bleeding, d/c, pelvic pain, growth on cervix may palpate/see mass on exam
Classic presentation: post coital bleeding, pelvic pain/pressure, abnormal vaginal
bleeding rectal/bladder sx
Types: Squamous large cell, keratinizing, non-keratinizing, small cell (worse prog)
Adenocarcinoma
Mixed carcinoma
Glassy cell – occurs in pregnant women usually fatal
RF: tobacco # of sex partners, age of onset of sex, # STDs, HIV (cervical CA an AIDS defining
illness)
OVARIAN TUMORS
RF: family hx, uninterrupted ovulation, nulitips, low fertility, delayed childbearing, late onset
menopause (OCs have protective effect)
SX: asymptomatic until advanced stages, urinary frequency, dysuria, pelvic pressure, ascites, - -
Types:
Epithelial (80%)
o Serous cystadenoma: papillary cystic malignant bilateral, psammonma bodies
o Endometroid: solid
o Mucinous: cystic
o Clear cell: associated with Hobnail Cells on path, assn with DES
o Brunner: look like transitional epithelium: Walthard Nests 99% benign
o SUET: solid undiff
Germ Cell
o Dysgerminoma: younger people, solid radiosensitive, lymphocytic infiltrate
o Teratoma: ectoderm endoderm mesoderm, Rotikansky’s protuberance, complications:
medical: struma ovarii, autoimmune hemolytic anemia, carcinoid
surgery: torsion, acute abdomen
o Primary choriocarcinoma of the ovary false, + UPT, increased HCG
o Yolk Sac Tumor/Endodermal Sinus: +AFP/LDH, +Schuller Duval Bodies
o Mixed germ cell: HCG, AFP, LDH, CA 125
Stromal
-older women (50-80)
-Sex cords hormone production
o Fibroma: Meig’s syndrome: ovarian tumor, r hydrothorax, ascites
o Granulosa Theca – feminizing, late recurrence, Call Exner Bodies, produce large
amounts of estrogen.
o Sertoli Leidig – masculinizing, secrete testosterone, Crystaloids of Reinke secrete
androgens
o Gynandroblastoma- components of male and female
Other
o Hilar Cell: hillus, androgenic, small
o Krukenberg: GI metastasis
bilateral enlarged solid ovaries
signet ring cell associated with mucus
assn with gastric cancer
CA OF FALLOPIAN TUBES
-adeno CA from mucosa
-disease progresses like ovarian CA
-peritoneal spread
-ascites
-bilateral in 10-20% results from mets often
-primary in very rare
-asymptomatic but may have vague lower abdominal pain and discharge
TX: TAH/BSO cisplatin, cyclophosphomide XRT
TROPHOBLASTIC DISEASE
Moles
Complete:
-<20 yrs or >40 yrs, 80% of molar pregnancies
-Complete 46xx (both x from sperm)
-worse b/c can transform into malignant- 20 % malignant
-no baby parts
Incomplete: Triploid (usually XXY)
-May have baby parts
CONTRACEPTION
Rhythm
Fertility awareness/abstinences
55-80% effective
ovulation assment = BBT
menstrual cycle tracking
cervical mucus exam
Coitus Interuptus
Withdrawal before ejaculation
15-25% failure
Lactational Amenorrhea
Nursing delays ovulation by hypothalamic suppression
Max of 6 months
50% ovulate by 6-12 months
15-55% get pregnant while nursing
Barrier
Male and female condom, diaphragm, cervical cap sponge, spermacide
IUD
Spermicidal inflammatory response/ inhibition of implantation
Used when OCPs contraindicated
Patient is a low STD risk
Contraindicated in pregnancy, abnormal vaginal bleeding, infection
Relative contraindication: nullip, prior ectopic, h/o STD, mod/sev dysmenorrhea
Failure rate <2%
Deproprovera
Medoxyprogesterone acetate
IM slow release of over 3 months
.3% failure rate
side effects: irregular menstrual bleeding, depression, weight gain
>70% get irregular menses, eventually have amenorrhea
Vasectomy
Ligation of the vas deferens
<1% failure rate
must use condom for 4-6 wks until azospermia confirmed on semen analysis
70% reanastomose resulting in pregnancy 18-60%
50% make anti-sperm antibodies
Tubal Sterilization
Most used method of birth control
4% failure rate
No side effects
Permanent although 1% seek reversal which is successful in 41-84%
1/1,500 risk of ectopic
4/100,000 mortality rate
TYPES:
Monophasic – fixed dose of estrogen and progesterone
Multphasic varies progesterone dose each week and lower overall estrogen/prog
Progesterone progestin only not as effective as combination OCPs
COMPLICATIONS:
Thromboembolism ( do not give in women with family history of DVT or PE), PE, CVA,
MI, HTN
Benefits of OCP:
Decrease ovarian/endometrial ca (BY 50%!!!), ectopic, anemia, pid, cysts, benign breast
dz, osteoporosis.
THERAPUTIC AB
25% of pregnancies end in therapeutic ab
Risk of death < 1/100,000 (anesthesia)
Vaginal evacuation – suction curettage, D & C/E
Induction of labor
Medical TX :
o Antiprogestin agent (RU-486 – mifepristone : blocks effects of progesterone) 1st
½ of 1st trimester.
o Post coital pill – high doses of estrogen that either suppresses ovulation or
accelerates ovum thru tube so no fertilization se: N/V
2 Term
nd
Congenital anomalies
Vaginal prostaglandin
D&E
Induction of labor w/ hypertonic solution (saline, urea, PGF, PGE vaginal suppositories)